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What Is Open Enrollment?
Open Enrollment is a period each year when changes can be made to Affordable Care Act (ACA) plans. During Open Enrollment, Texas consumers can evaluate their plan options for the coming year and change coverage with a January 1 effective date. Open Enrollment is also the time if individuals have qualified for subsidies, which are paid by the federal government, that their subsidy application is updated, and the subsidy amount is adjusted and applied to next year’s premium. All changes to coverage must be completed during Open Enrollment or an individual must qualify for a Special Enrollment Period to be insured by an ACA plan after the close of Open Enrollment.
Special Enrollment Period (SEP)
An individual also has a Special Enrollment Period (SEP) if the individual experiences a Qualifying Life Event (QLE) outside of the annual Open Enrollment Period.
- Loss of Essential Health Coverage – includes loss of employer coverage or loss of Medicaid or CHIP as a result of a reported change in household income or other circumstances.
- Change In Family Size – marriage, divorce, death of a family member, birth, or adoption.
- Change In Citizenship – gaining status as a citizen or a lawfully present individual in the U.S.
- Enrollment Error – experienced an error in your original enrollment.
- Violation of Plan Benefits – an individual who enrolled in a qualified health plan and is able to demonstrate that the plan substantially violated a material provision of the plan.
- Change In Premium Subsidy Eligibility – becoming newly eligible or newly ineligible for the premium subsidy or cost sharing reductions.
- Relocation – new plans become available based on moving to a new area.
- Native American and Indian – the individual is an Indian, as defined by the Indian Health Care Improvement Act.
- Exceptional Circumstances – a qualified enrollee is subject to other exceptional circumstances as determined by the Exchange.
Typically, if an individual is applying during a SEP, they will be required to provide documentation that a life event has occurred. Either the Health Insurance Marketplace or the insurance carrier will review the documentation to verify that the individual qualifies for the SEP.
If an individual qualifies for a subsidy based on their household income, the amount of the subsidy, which is paid by the federal government directly to the insurance carrier, is used to reduce the monthly premium. Many times, depending on income, the subsidy can pay the full amount of the premium.
The below chart details the Federal Poverty Level amounts, per household, that qualify for subsidies.
|Federal Poverty Level (Low)||Federal Poverty Level (High)|